Herpes- Simplex Corneal Ulcer

Herpes simplex keratitis

Enlarged corneal nerves not seen in Herpes simplex keratitis.

Ref:Color Atlas of Ophthalmology: The Quick-Reference Manual for Diagnosis and Treatment By Amar Agarwal, Soosan Jacob, 2009, Page 191

A i.e. Herpes virus

C i.e. Herpes simplex virus

A i.e. Herpes simplex

• Decreased corneal sensations, dendritic and geographical ulcers are characteristic features of Herpes simplex ocular disease Q

Sensory supply of cornea is through trigeminal nerve Q. Neurotrophic keratopathy occurs due to paralysis of sensory supply of cornea. Causes of neurotrophic keratopathy or anaesthetic cornea are:

D i.e. Idoxuridine

• Drug of choice for herpetic keratitis is Acyclovir Q (topical)
• Other antiviral drugs used are

– Idoxuridine

– Trifluorothyrnidine

– Vidarabine

C i.e. Disciform keratitis

• Both topical antiviral and topical steroid used for treatment Q in Stromal Keratitis (Disciform keratitis & Diffuse stromal necrotic keratitis)
• Corticoseroids are used topically & as sub-conjuctival injection in Uveitis. Acute cases of pars planitis/intermediate uveits/ chronic posterior cyclitis resolve spontaneously, but chronic cases have poor prognosis, though corticosteriods have a place in treatment.
• Options (A) & (B) are contra-indications of steroids.

Ans. Nummular keratitis

Ans. Pimarcin

Ans: D i.e. Dexamethasone

Drugs & epithelial keratitis

• Epithelial keratitis responds well to topical antivirals (5% IDU/ idoxuridine drops) which are prescribed along with topical antibiotics to prevent secondary bacterial infection, lubricants to relieve discomfort & cycloplegics
• It is uniformly accepted that topical steroids are contraindicated in the presence of active viral replication as occurs in herpes simplex epithelial keratitis

Ans. D: Herpes simplex keratitis

The resulting ulcer is visible with fluorescein staining and has a delicate branching pattern, hence the name dendritic ulcer. When clinically suspected definitive diagnosis can be arrived at using

Immunofluorescence assay (IFA) for HSV-1 antigen, and

– Polymerase chain reaction (PCR) for HSV-1 DNA

A herpes simplex keratitis may present as an irritable eye without serious discomfort. May present as 4 clinical entities:

– Infectious epithelial keratitis (with characteristic dendritic ulcers)

– Neurotrophic keratopathy

– Stromal keratitis

– Endotheliitis (classified as disciform, diffuse, or linear)

Recurrence of herpes simplex keratitis is common and the same side is usually affected. If the corneal infection is more deep seated there may be corneal thickening and central opacification. This is called disciform keratitis.

Ans. is ‘c’ i.e., Endothelium

Herpetic Keratitis

Most of the ocular infection are caused by HSV-1 except in neonates where eye infection can be caused by HSV­2 through infected genitalia of mother. Ocular involvement by HSV may occur in two forms : ‑

A) Primary herpes : – Typically is a unilateral blepharoconjunctivitis which is characterized by vesicles on the skin of lids, follicular conjunctivitis, preauriculars adenopathy and sometimes punctate keratitis.

B) Recurrent ocular herpes : – After primary infection, recurrent disease may involve any or all layers of the cornea.

Recurrent herpatic keratitis is divided into : ‑

1) Epithelial keratitis : – Manifestations of epithelial keratitis include : –

1. Corneal vesicles : – Vesicles coalesce and erupt to form dendritic or geographic ulcer.
2. Superficial punctate keratitis
3. Dendritic ulcer: – It is the most common presentation and is a typical lesion of herpes keratitis. There is an associated marked diminution of sensation.
4. Geographic ulcer (amoeboid ulcer)

2) Stromal keratitis : – Stromal keratitis may be of two types : –

1. Disciform keratitis : – This is due to damage to endothelial cells as a result of hypersensitivity reaction to the HSV antigen.
2. Diffuse stromal necrotic keratitis : – Caused by active viral invasion and tissue destruction.

3) Metaherpatic keratitis (Epithelial sterile trophic ulceration) : – It is not an active disease, but is a mechanical healing problem at the site of previous herpetic ulcer.

Ans. is  c  i.e., Herpetic corneal ulcer 

        Primary herpes : – Typically is a unilateral blepharoconjunctivitis which is characterized by vesicles on the skin of lids, follicular conjunctivitis, preauriculars adenopathy and sometimes punctate keratitis.

        Recurrent ocular herpes : – After primary infection, recurrent disease may involve any or all layers of the cornea. Recurrent herpatic keratitis is divided into : ‑

1) Epithelial keratitis : – Manifestations of epithelial keratitis include : –

1. Corneal vesicles : – Vesicles coalesce and erupt to form dendritic or geographic ulcer.
2. Superficial punctate keratitis
3. Dendritic ulcer: – It is the most common presentation and is a typical lesion of herpes keratitis. There is an associated marked diminution of sensation.
4. Geographic ulcer (amoeboid ulcer)

2) Stromal keratitis : – Stromal keratitis may be of two types : –

1.       Disciform keratitis : – This is due to damage to endothelial cells as a result of hypersensitivity reaction to the HSV antigen.
2.       Diffuse stromal necrotic keratitis : – Caused by active viral invasion and tissue destruction.

3) Metaherpatic keratitis (Epithelial sterile trophic ulceration) : – It is not an active disease, but is a mechanical healing problem at the site of previous herpetic ulcer.